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Based upon record review and interviews, the hospital failed to ensure for 1 of 10 (#4) Emergency Department records reviewed, the Registered Nurse documented interventions related to patient care was promptly entered in the medical record. Findings:

On 02/06/24 at 11:00 a.m. patient #4, a 90 year old male, presented to the Emergency Department by ambulance with the chief complaint of altered mental status and admitted to the hospital on 02/07/24 at 2:51 p.m.

Further review of the Emergency Department record revealed the following addendum was added to the medical record on 02/07/24 at 7:24 p.m. by Staff G "Patient attempting to pull at foley catheter. Multiple attempts to reorient patient failed. Patient placed in mitts for his safety. Skin tears found on bilateral arms and bandaged appropriately." There failed to be further documentation by Staff G related to the number of tears, the location, how the skin tears occurred and the type of would care and dressings provided.

Interview with Staff D on 03/18/24 at 11:50 a.m. revealed after reviewing patient #4's Emergency Department record, she instructed Staff G to complete an addennum related to the application of the mittens for safety and the skin tears which had occurred while the patient was in the Emergency Department.